Digging deep: Is intentional non-adherence among patients a thing?

Adherence to the treatment regimen is a vital step to ensure illnesses are well controlled, but many patients fail to do so.

When a pharmacist or doctor hands over medication to a patient, an assumption occurs – that the patient will take it as instructed. On the contrary, many do not, and there are studies as proof.

According to the World Health Organisation (WHO), only around half of medicines for long-term conditions are taken as prescribed in developed countries and there are very little improvement rates over the past five decades. There is also no one-stop solution yet.

Medication adherence is considered the final frontier to preserve the health of a population. Full benefits of pharmacotherapy may go to waste for a simple action of non-adherence, costing up to billions of dollars – which could be better utilised for other healthcare needs.

Hitting the wrong target

In recent years, “smart” pill boxes – which text or email reminders to patients or utilise sensor technology to track if a pill has been consumed – have surfaced on the market. Although some have had some success, none have completely eradicated the problem.

Conventional understanding put the blame on patient forgetfulness, diminished dexterity or complicated treatment regimen. No doubt these factors contribute to the problem, but the oversimplification of non-adherence causes, may dismiss the underlying interplay between psychological, behavioural and socio-economic reasons of the problem. Significant variation between individual patients further complicates the matter.

“Traditionally, everyone’s been focused on education, but over the past 25 years, we’ve all seen that we can’t simply educate our way out of this – there are so many other factors at play. Don’t chronically ill patients realise they could die from this? Of course they do, but for so many reasons large and small, many still don’t faithfully take their medications,” said Heather Black, the Director of Health Quality Research for Merck’s Centre for Observational and Real-world Evidence, when interviewed by Pharmaceutical Commerce.

The healthcare industry has aimed at addressing patient “forgetfulness” to eliminate non-adherence, but studies have shown that this has failed to show any improvement.

While studies revealed a significant proportion of patients simply forgot to take their medication, many interventions that aimed at addressing patient “forgetfulness” failed to show any improvement. Such findings held true regardless if a high-tech reminder system was used, as in the HeartStrong randomised clinical trial, or low costs intervention in the REMIND trial.

The missing link, may lie in the mismatch between a patient's understanding of disease severity and the extent of their acknowledgement that medication is truly necessary to control the disease.

A study published by Omnicell Ltd in 2015 found that one in five patients surveyed have admitted to stopping their chronic medications for hypertension or hyperlipidaemia because “they did not feel ill and decided they did not need them.”

As Debi Bhattacharya, a senior lecturer in pharmacy practice at the University of East Anglia suggested, there are three main components to adherence.

“Does the patient have access to the medication? Do they have the cognitive and physical ability to take it? And do they have the motivation to take it? I think the third element, where we are talking about the psychosocial impact of medicines and how to positively influence that, is where the real challenge is for all healthcare professionals,” she said.

Conceptualising medication adherence as a moving target

By large, healthcare professionals know how to address the former two aspects, however, understanding the true reasons behind an individual patient’s decision to skip their regular medicine can be more complex.

Bhattacharya said that patients are more willing to discuss barriers to access and cognitive or physical ability, but less willing to discuss intentional non-adherence.

Healthcare professionals should spend sufficient amount of time with their patients in order to elicit information on barriers to medication adherence.

The acceptance by healthcare professionals that medication adherence is a moving target that differs from one patient to another is a vital element in combating the problem – and also a real challenge.

Although many healthcare providers are trained in effective communication skills, specific training to elicit information on barriers to medication adherence is rarely provided, let alone any education on the behavioural-change technique that will aid a patient-centric consultation.

Heidi Wright, practice and policy lead for England at the Royal Pharmaceutical Society, advocates pharmacists to “make use of general health coaching as well as training on shared decision-making”.

Pharmacists as the front-line warriors

Pharmacists, especially those working in the community setting, have a bigger role to play in improving adherence among patients.

“People want care; they want that human interaction,” said Tom Kenny, a former GP and chief executive officer of Spoonful of Sugar, a London-based behaviour-change consultancy firm.

“There is good evidence that pharmacists, if they’re trained up in some simple techniques, can be really effective at improving adherence for patients," he added.

However, community pharmacists are usually too busy to afford the quality patient time. Hence, a proper compensation could be a possible remedy.

“To make these initiatives sustainable and scalable, we need payers to pay for them. Once you can show the reduction in hospitalisation costs related to improved drug adherence, such an investment begins to make sense,” highlighted Michael Wolf, managing director at KPMG. MIMS

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